Method and Apparatus for Coupling Soft Tissue to a Bone

ABSTRACT

A method for coupling soft tissue to bone including: positioning a first anchor in a first bone bore, the first anchor having a first self-locking adjustable suture construct including a first adjustable loop, a second adjustable loop, and a pair of first ends; positioning a second anchor in a second bone bore, the second anchor having a second self-locking adjustable suture construct including a third adjustable loop, a fourth adjustable loop, and a second end; positioning the first adjustable loop relative to the soft tissue; positioning the second adjustable loop about the third adjustable loop; and tensioning the pair of first ends and the second end to pull the first adjustable loop against the soft tissue, couple the second adjustable loop to the third adjustable loop, pull the second adjustable loop against the soft tissue, and pull the third adjustable loop against the soft tissue.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.12/474,802 filed on May 29, 2009; which is a continuation-in-part of:(1.) U.S. patent application Ser. No. 11/541,506 filed on Sep. 29, 2006,now U.S. Pat. No. 7,601,165 issued on Oct. 13, 2009; (2.) U.S. patentapplication Ser. No. 11/541,505 filed on Sep. 29, 2006, now U.S. Pat.No. 7,658,751 issued on Feb. 9, 2010; (3.) U.S. patent application Ser.No. 12/014,399 filed on Jan. 15, 2008, now U.S. Pat. No. 7,909,851issued on Mar. 22, 2011; (4.) U.S. patent application Ser. No.12/014,340 filed on Jan. 15, 2008, now U.S. Pat. No. 7,905,904 issued onMar. 15, 2011; (5.) U.S. patent application Ser. No. 11/935,681 filed onNov. 6, 2007, now U.S. Pat. No. 7,905,903 issued on Mar. 15, 2011; (6.)U.S. patent application Ser. No. 11/869,440 filed on Oct. 9, 2007, nowU.S. Pat. No. 7,857,830 issued on Dec. 28, 2010; (7.) U.S. patentapplication Ser. No. 11/784,821 filed on Apr. 10, 2007; (8.) U.S. patentapplication Ser. No. 11/347,661 filed on Feb. 3, 2006, now U.S. Pat. No.7,749,350 issued on Jul. 6, 2010; (9.) U.S. patent application Ser. No.11/347,662 filed on Feb. 3, 2006.

This application is also a continuation-in-part of: (1.) U.S. patentapplication Ser. No. 12/196,405 filed on Aug. 22, 2008; (2.) U.S. patentapplication Ser. No. 12/196,407, filed on Aug. 22, 2008; and (3.) U.S.patent application Ser. No. 12/196,410, filed on Aug. 22, 2008.

The disclosures of the above applications are incorporated herein byreference.

FIELD

The present disclosure relates to method of coupling soft tissue and,more particularly, to a method of coupling soft tissue to a bone.

BACKGROUND

The statements in this section merely provide background informationrelated to the present disclosure and may not constitute prior art.

It is commonplace in arthroscopic procedures to employ sutures andanchors to secure soft tissues to bone. Despite their widespread use,several improvements in the use of sutures and suture anchors may bemade. For example, the procedure of tying knots may be very timeconsuming, thereby increasing the cost of the procedure and limiting thecapacity of the surgeon. Furthermore, the strength of the repair may belimited by the strength of the knot. This latter drawback may be ofparticular significance if the knot is tied improperly as the strengthof the knot in such situations may be significantly lower than thetensile strength of the suture material.

To improve on these uses, sutures having a single preformed loop havebeen provided. FIG. 1 represents a prior art suture construction. Asshown, one end of the suture is passed through a passage defined in thesuture itself. The application of tension to the ends of the suturepulls a portion of the suture through the passage, causing a loop formedin the suture to close. Relaxation of the system, however may allow aportion of the suture to translate back through the passage, thusrelieving the desired tension.

It is an object of the present teachings to provide an alternativedevice for anchoring sutures to bone and soft tissue. The device, whichis relatively simple in design and structure, is highly effective forits intended purpose.

SUMMARY

This section provides a general summary of the disclosure, and is not acomprehensive disclosure of its full scope or all of its features.

The present teachings provide for a method for coupling soft tissue tobone. The method includes the following: forming a first bore in a bone;forming a second bore in the bone; positioning a first anchor in thefirst bore, the first anchor having a first self-locking adjustablesuture construct extending therefrom, the first construct including afirst adjustable loop, a second adjustable loop, and a pair of firstends; positioning a second anchor in the second bore, the second anchorhaving a second self-locking adjustable suture construct extendingtherefrom, the second construct including a third adjustable loop, and asecond end; positioning the first adjustable loop relative to the softtissue; positioning the second adjustable loop about the thirdadjustable loop; and tensioning the pair of first ends and the secondend to pull the first adjustable loop against the soft tissue, couplethe second adjustable loop to the third adjustable loop, pull the secondadjustable loop against the soft tissue, and pull the third adjustableloop against the soft tissue to thereby couple the soft tissue to thebone.

The present teachings also provide for a method for coupling soft tissueto bone that includes the following: inserting a first anchor in a firstbone bore, the first anchor having a first self-locking adjustablesuture construct extending therefrom, the first construct including afirst adjustable loop, a second adjustable loop, and a pair of firstends; inserting a second anchor in a second bone bore, the second anchorhaving a second self-locking adjustable suture construct extendingtherefrom, the second construct including a third adjustable loop, and asecond end; positioning the first adjustable loop relative to the softtissue; compressing a first coupling element connected to the firstadjustable loop against the soft tissue by tensioning the pair of firstends; and connecting the second adjustable loop to the third adjustableloop with a second coupling element and compressing both the secondadjustable loop and the first adjustable loop against the soft tissue bytensioning the pair of first ends and the second end.

The present teachings further provide for a method for coupling softtissue to bone including: positioning a first anchor in a first bonebore, the first anchor having a first self-locking adjustable sutureconstruct extending therefrom, the first construct including a firstadjustable loop, a second adjustable loop, and a pair of first ends;positioning a second anchor in a second bone bore, the second anchorhaving a second self-locking adjustable suture construct extendingtherefrom, the second construct including at least a third adjustableloop, and at least one second end; positioning the first adjustable loopabout a first portion of the soft tissue; collapsing a first couplingelement connected to the first adjustable loop against the soft tissueby tensioning the pair of first ends; collapsing a second couplingelement connected to the third adjustable loop against the secondadjustable loop to couple the second adjustable loop to the thirdadjustable loop by tensioning the second end; and compressing the secondadjustable loop and the third adjustable loop against the soft tissue bytensioning both the pair of first ends and the second end.

Further areas of applicability will become apparent from the descriptionprovided herein. It should be understood that the description andspecific examples are intended for purposes of illustration only and arenot intended to limit the scope of the present disclosure.

DRAWINGS

The drawings described herein are for illustration purposes only and arenot intended to limit the scope of the present disclosure in any way.

FIG. 1 represents a prior art suture configuration;

FIGS. 2A and 2B represent suture constructions according to theteachings;

FIG. 3 represents the formation of the suture configuration shown inFIG. 2A;

FIGS. 4A and 4B represent alternate suture configurations;

FIGS. 5-7 represent further alternate suture configurations;

FIG. 8 represents the suture construction according to FIG. 5 coupled toa bone engaging fastener;

FIGS. 9-11 represent the coupling of the suture construction accordingto FIG. 5 to a bone screw;

FIGS. 12A-12E represent the coupling of a soft tissue to an ACLreplacement in a femoral/humeral reconstruction;

FIGS. 13A-13D represent a close-up view of the suture shown in FIGS.1-110;

FIGS. 14A and 14B represent the coupling of the suture construction ofFIG. 2A and FIG. 4 to bone;

FIGS. 15A-15G represent the coupling of soft tissue to a bone accordingto the present teachings;

FIGS. 16A-16D represent the coupling of soft tissue to a bone usingalternate teachings;

FIGS. 17A-17E represent the coupling of soft tissue to a bone usingalternate teachings;

FIGS. 18A-18B represent the coupling of soft tissue to a bone usingmultiple collapsible loop structures;

FIGS. 19A-19C represent the coupling of soft tissue to a bone using yetalternate teachings;

FIGS. 20A and 20B represent a meniscal repair according to the presentteachings;

FIG. 21 represents an insertion tool with associated fastener and softtissue anchor;

FIG. 22 represents an insertion sleeve associated with the tool shown inFIG. 21;

FIGS. 23-31 represent the repair of a rotator cuff using a tool shown inFIG. 21;

FIGS. 32-38 represent alternate methods for tying a suture anchor to thefastener;

FIG. 39 represents the suture anchor coupled to a two-piece fastener;and

FIGS. 40-44 represent an alternate system and method of coupling softtissue to the bone.

DETAILED DESCRIPTION

The following description is merely exemplary in nature and is notintended to limit the present disclosure, application, or uses. Itshould be understood that throughout the drawings, correspondingreference numerals indicate like or corresponding parts and features.

FIG. 2A represents a suture construction 20 according to the presentteachings. Shown is a suture 22 having a first end 24 and a second end26. The suture 22 is formed of a braided body 28 that defines alongitudinally formed hollow passage 30 therein. First and secondapertures 32 and 34 are defined in the braided body 28 at first andsecond locations of the longitudinally formed passage 30.

Briefly referring to FIG. 3, a first end 24 of the suture 22 is passedthrough the first aperture 32 and through longitudinal passage 30 formedby a passage portion and out the second aperture 34. The second end 26is passed through the second aperture 34, through the passage 30 and outthe first aperture 32. This forms two loops 46 and 46′. As seen in FIG.2B, the relationship of the first and second apertures 32 and 34 withrespect to the first and second ends 24 and 26 can be modified so as toallow a bow-tie suture construction 36. As described below, thelongitudinal and parallel placement of first and second suture portions38 and 40 of the suture 22 within the longitudinal passage 30 resiststhe reverse relative movement of the first and second portions 38 and 40of the suture once it is tightened.

The first and second apertures are formed during the braiding process asloose portions between pairs of fibers defining the suture. As furtherdescribed below, the first and second ends 24 and 26 can be passedthrough the longitudinal passage 30 multiple times. It is envisionedthat either a single or multiple apertures can be formed at the ends ofthe longitudinally formed passage.

As best seen in FIGS. 4A and 4B, a portion of the braided body 28 of thesuture defining the longitudinal passage 30 can be braided so as to havea diameter larger than the diameter of the first and second ends 24 and26. Additionally shown are first through fourth apertures 32, 34, 42,and 44. These apertures can be formed in the braiding process or can beformed during the construction process. In this regard, the apertures32, 34, 42, and 44 are defined between adjacent fibers in the braidedbody 28. As shown in FIG. 4B, and described below, it is envisioned thesutures can be passed through other biomedically compatible structures.

FIGS. 5-7 represent alternate constructions wherein a plurality of loops46 a-d are formed by passing the first and second ends 24 and 26 throughthe longitudinal passage 30 multiple times. The first and second ends 24and 26 can be passed through multiple or single apertures defined at theends of the longitudinal passage 30. The tensioning of the ends 24 and26 cause relative translation of the sides of the suture with respect toeach other.

Upon applying tension to the first and second ends 24 and 26 of thesuture 22, the size of the loops 46 a-d is reduced to a desired size orload. At this point, additional tension causes the body of the suturedefining the longitudinal passage 30 to constrict about the parallelportions of the suture within the longitudinal passage 30. Thisconstriction reduces the diameter of the longitudinal passage 30, thusforming a mechanical interface between the exterior surfaces of thefirst and second parallel portions as well as the interior surface ofthe longitudinal passage 30.

As seen in FIGS. 8-11, the suture construction can be coupled to variousbiocompatible hardware. In this regard, the suture construction 20 canbe coupled to an aperture 52 of the bone engaging fastener 54.Additionally, it is envisioned that soft tissue or bone engaging members56 can be fastened to one or two loops 46. After fixing the boneengaging fastener 54, the members 56 can be used to repair, forinstance, a meniscal tear. The first and second ends 24, 26 are thenpulled, setting the tension on the loops 46, thus pulling the meniscusinto place. Additionally, upon application of tension, the longitudinalpassage 30 is constricted, thus preventing the relaxation of the tensioncaused by relative movement of the first and second parallel portions38, 40, within the longitudinal passage 30.

As seen in FIGS. 9-11B, the loops 46 can be used to fasten the sutureconstruction 20 to multiple types of prosthetic devices. As describedfurther below, the suture 22 can further be used to repair and couplesoft tissues in an anatomically desired position. Further, retraction ofthe first and second ends allows a physician to adjust the tension onthe loops between the prosthetic devices.

FIG. 11 b represents the coupling of the suture construction accordingto FIG. 2B with a bone fastening member. Coupled to a pair of loops 46and 46′ are tissue fastening members 56. The application of tension toeither the first or second end 24 or 26 will tighten the loops 46 or 46′separately.

FIGS. 12A-12E represent potential uses of the suture constructions 20 inFIGS. 2A-7 in an ACL repair. As can be seen in FIG. 12A, thelongitudinal passage portion 30 of suture construction 20 can be firstcoupled to a fixation member or fastener 60. The fixation member 60 canhave a first profile which allows insertion of the fixation member 60through the tunnel and a second profile which allows engagement with apositive locking surface upon rotation. The longitudinal passage portion30 of the suture construction 20, fixation member 60, loops 46 and ends24, 26 can then be passed through a femoral and tibial tunnel 62. Thefixation member 60 is positioned or coupled to the femur. At this point,a natural or artificial ACL 64 can be passed through a loop or loops 46formed in the suture construction 20. Tensioning of the first and secondends 24 and 26 applies tension to the loops 46, thus pulling the ACL 64into the tunnel. In this regard, the first and second ends are pulledthrough the femoral and tibial tunnel, thus constricting the loops 46about the ACL 64 (see FIG. 12B).

As shown, the suture construction 20 allows for the application of forcealong an axis 61 defining the femoral tunnel. Specifically, theorientation of the suture construction 20 and, more specifically, theorientation of the longitudinal passage portion 30, the loops 46, andends 24, 26 allow for tension to be applied to the construction 20without applying non-seating forces to the fixation member 60. As anexample, should the loops 24, 26 be positioned at the fixation member60, application of forces to the ends 24, 26 may reduce the seatingforce applied by the fixation member 60 onto the bone.

As best seen in FIG. 12C, the body portion 28 and parallel portions 38,40 of the suture construction 20 remain disposed within to the fixationmember 60. Further tension of the first ends draws the ACL 64 up throughthe tibial component into the femoral component. In this way, sutureends can be used to apply appropriate tension onto the ACL 64 component.The ACL 64 would be fixed to the tibial component using a plug or screwas is known.

After feeding the ACL 64 through the loops 46, tensioning of the endsallows engagement of the ACL with bearing surfaces defined on the loops.The tensioning pulls the ACL 64 through a femoral and tibial tunnel. TheACL 64 could be further coupled to the femur using a transverse pin orplug. As shown in FIG. 12E, once the ACL is fastened to the tibia,further tensioning can be applied to the first and second ends 24, 26placing a desired predetermined load on the ACL. This tension can bemeasured using a force gauge. This load is maintained by the sutureconfiguration. It is equally envisioned that the fixation member 60 canbe placed on the tibial component 66 and the ACL pulled into the tunnelthrough the femur. Further, it is envisioned that bone cement orbiological materials may be inserted into the tunnel 62.

FIGS. 13A-13D represent a close-up of a portion of the suture 20. As canbe seen, the portion of the suture defining the longitudinal passage 30has a diameter d₁ which is larger than the diameter d₂ of the ends 24and 26. The first aperture 32 is formed between a pair of fiber members.As can be seen, the apertures 32, 34 can be formed between two adjacentfiber pairs 68, 70. Further, various shapes can be braided onto asurface of the longitudinal passage 30.

The sutures are typically braided of from 8 to 16 fibers. These fibersare made of nylon or other biocompatible material. It is envisioned thatthe suture 22 can be formed of multiple type of biocompatible fibershaving multiple coefficients of friction or size. Further, the braidingcan be accomplished so that different portions of the exterior surfaceof the suture can have different coefficients of friction or mechanicalproperties. The placement of a carrier fiber having a particular surfaceproperty can be modified along the length of the suture so as to placeit at varying locations within the braided constructions.

FIGS. 14A and 14B represent the coupling of suture construction 22 ofFIG. 2A and FIG. 4 to a bone. The longitudinal passage 30 is coupled toa fixation member 60 which can be disposed within an aperture formed inthe bone. The fixation member 60 can be, for example, a staple or a boneengaging screw. After coupling the suture construction 22 to the bone,loops 46 and 47 and ends 24 and 26 are readily accessible by thephysician. The application of tension to the ends 24 and/or 26 causesthe loops 46 and 47 to constrict. The loops 46 and 47 can be used tocouple two or more portions of the anatomy. In this regard, the loopscan be used to couple bone to bone or soft tissue to bone.

FIGS. 15A-15G represent the coupling of soft tissue 80 to bone. As shownin FIGS. 15A and 15B, the suture construction 22 is disposed about aportion of the soft tissue 80. Alternatively, an aperture or hole 84 canbe formed in the soft tissue 80. A portion of the suture construction22, for example, a loop 46 or loops 46, 47 or ends 24 and 26 can bethreaded or pulled through the aperture 84. As seen in FIG. 15B, asingle loop 46 of suture can be coupled to the fastener 60. This singleloop 46 can be disposed over or around the soft tissue 80.

As shown in FIG. 15C, one loop 46 can have a fastening element 70coupled thereto. This fastener element 70 can take the form of a loop ofsuture having a knot 72. This fastening element 70 along with the loop46 and one or more strands 24 can be passed through the aperture 84formed in the soft tissue 80.

FIG. 15D shows the second loop 47 can be passed around the soft tissueand coupled to the fastening element 70. The first and second loops 46and 47 are coupled together about the soft tissue 80, and optionally canbe positioned about the knot 72.

As shown in FIG. 15E, the first loop 46 and first end 24 can be passedthrough an aperture 84 of the soft tissue 80. Coupled to the first loop46 is a fastener 70 in the form of a suture having a knot 72. The secondloop 47 can be passed through the suture 70 and the knot 72 so as toform a pair of locking loops 73 (see FIG. 15F). FIG. 15G shows thattension can be applied to the first and second ends 24 and 26 of thesuture 22 to constrict the suture 22 about the soft tissue 80. In thisregard, the first and second loops 46 and 47 are tightened to constrictabout and fix the soft tissue 80 to the bone.

As seen in FIG. 16A, the construction of FIGS. 14A and 14B can bemodified so as to place a pair of collapsible fabric tubes 74 and 76about a portion of the suture 22. In this regard, collapsible tubes 74and 76 can be coupled to the first and second suture loops 46 and 47. Itis also envisioned several collapsible tubes can be coupled to a singleloop 46 or the suture ends 26, 27.

The collapsible tubes 74 and 76 can be either threaded onto (76) ordisposed about a loop 75 formed in the suture loop 46. As seen in FIG.16B, the first collapsible tube 76 can be fed through the loop 75. Whentension is applied to the second end 26 of the sutures 47, the firstloop 46 constricts about the second loop causing the collapse of thefirst collapsible tube 74. As shown in FIG. 16D, tension can be appliedto the first suture end 24 causing the second loop 47 to constrictcausing the collapse of the second collapsible tube 76 and thesubsequent locking of the soft tissue 80 to the bone.

FIGS. 17A-17E represent an alternate method for coupling soft tissue 80to a bone using the construction of FIGS. 14A and 14B. As shown in FIG.17A, the first loop 46 and first suture end 24 are passed through anaperture 84 formed in the soft tissue 80. The second loop 47 is passedthrough the first loop 46.

The second loop 47 is then doubled back over the first loop 46 causing apair of intermediate loops 77. As shown in FIG. 17D, a locking member70, soft or hard, can then be passed through the pair of intermediateloops 77 or a portion of the first loop 75 to lock the first and secondloops 46 and 47 together. As shown in FIG. 17E, tension applied to thesuture ends 26, 27 tighten the loops 46 and 47 about the locking member70. The soft tissue 80 is also fixed to the bone.

FIGS. 18A-18C represent alternate suture constructions 22 which are usedto couple soft tissue 80 and 81 to bone. Disposed about the first andsecond loops 46 and 47 are collapsible tubes 74 and 76. The tubes 74 and76 which can be, for example, fabric or polymer, can either be directlydisposed about the suture 22 of the first and second loops 46 and 47, orcan be coupled to the suture loops 46 and 47 using a separate loopmember 81.

As shown in FIG. 18C, the suture construction 22 shown in FIG. 18A or18B, the collapsible tubes 74 and 76 are passed through the apertures 84formed in the soft tissue 80. The application of tension to the ends 26and 27 causes the soft tissue 80 to be drawn against the bone and causecompressive forces to be applied to the collapsible tubes 74 and 76. Bytightening the suture which passes through the passage 30, the softtissue 80 is coupled to the bone without the use of knots.

As can be seen in FIGS. 19A-19C, several fixation members 60 and 60′ canbe coupled to the suture construction 22 to fasten soft tissue 80 tobone. As seen in FIG. 19A, the collapsible tube 74 can be coupled to afirst loop 46 while the second loop 47 can be used to couple the firstsuture 22 to the second fastener 60′. In this regard, they are coupledusing a collapsible tube 76 of the second suture 22′, thus allowingdownward force along the entire length between the fasteners, thusproviding bridge fixation as well as point fixation.

As seen in FIG. 19B, tension of the ends 24 and 26 of the first suture22 draws the second loop 47 into the fixation member 60′. The secondloop 47 of the first suture 22 is then coupled to the collapsed tube 76.This couples the first and second fasteners together and applies thedownward force.

As seen in FIG. 19C, the second loop 47 of the first suture 22 can bepassed through a second aperture 86 in the soft tissue 80. A second loop47 is then coupled to the collapsible tube 76 associated with the secondsuture 22′. The collapsed tube 76 of the second suture 22′ functions tofix the suture 22′ to the fixation member 60′. It is envisioned thecollapsed tube 76 can be found within a bore defined in the bone or thefastener 60.

FIGS. 20A and 20B represent the use of a suture construction 22 torepair a meniscus. Fasteners 82 are coupled to first and second loops 46and 47. After the fixation member 60 is coupled to bone or soft tissue,the first loop 46 is passed through a first aperture 84 in a firstportion of the meniscus. The first loop and collapsible tube 74 is thenpassed through a second aperture 86 and a second portion of themeniscus. The second loop 47 and second collapsible tube 76 aresimilarly passed through the meniscus. Tension is applied to the firstand second ends 24 and 26 of the suture 22 to pull the meniscustogether. As seen in FIG. 20B, a first and second collapsible tube 74and 76 are constricted so as to couple the suture to the meniscus.

FIG. 21 represents a tool 100 with associated fastener 102 and softtissue anchor 104. The tool 100 has a handle portion 106 whichreleasably engages the fastener 102. Associated with the handle portion106 is a hollow longitudinal suture 103 which accepts a soft tissueanchor 104. Disposed at a distal end 110 of the hollow longitudinalportion 108 is a slot having a portion of the soft tissue anchor 104disposed therethrough. The distal end 110 is further configured tosupport the fastener 102 for insertion into a bore defined within bone112.

FIG. 22 represents an insertion guide 115 having a handle portion 114and a curved longitudinal guide tube 116. The longitudinal guide tube116 and handle portion 114 slidably accept the fastener 102 and softtissue anchor 104. The curved longitudinal tube 116 and handle portion112 define a slot 118 which also slidably accepts the suture 103 of softtissue anchor 104.

FIGS. 23-38 generally depict the repair of labral tissue of a glenoid.While the repair shown generally relates to a specific anatomicalinjury, it is envisioned the teachings herein can be applied to otheranatomical regions which require the coupling of soft tissue to bone.For example, a meniscal repair in a knee may be performed using similartechniques. As shown in FIG. 23, access to the region of the injury ismade through a tube 120. At this point, a collapsible tube 122 having anextended portion 124 is threaded through tube 120 into close proximityof the soft tissue 126 to be coupled to bone. A suture grabber 128 suchas a speed pass by Biomet Sports Medicine is used to pierce the softtissue 126 and to grab the extended portion 124 of the collapsible tube122. This extended portion 124 is then pulled through the soft tissue126.

As shown in FIG. 24, the extended portion 124 of the collapsible tube122 is fed back out the access tube 120 and clamped with clamp 129 so asto prevent inadvertent translation with respect to the tube. As shown inFIG. 25, the insertion sleeve 115 is placed through the access tube 120.The collapsible tube 122 is placed through the slot 118 defined in thehandle portion 114 and longitudinal guide tube 116.

FIG. 26 shows a drill 130 having a flexible drive shaft 132 and a bonecutting drill bit 134. The drill bit 134 is placed through the guidetube 116 to form a bore 136 in bone at a location adjacent to a softtissue repair. It is envisioned the bore 136 can be placed under oradjacent the soft tissue repair.

After the bore 136 has been formed in the bone, the tool 100, fastener102, and associated soft tissue anchor 104 are placed through theinsertion guide 115. As shown in FIG. 28, the fastener is inserted intothe bore 136. It is envisioned the fastener 102 can be a two-partfastener having a first insertion portion 140 and a locking portion 142.The locking portion 142 can have a plurality of expandable bone engagingmembers 144.

As seen in FIG. 30, the pair of sutures 146 can be pulled through thesoft tissue 126. The sutures 146 can be coupled together using a sutureconstruction shown in FIG. 1A or 1B. In this regard, the suture 146 canbe looped through an integrally formed collapsible member or tube 148which can be used to fix the suture construction with respect to eitherthe insert or locking portion 140, 142 of the fastener.

As shown in FIG. 31, when tension is applied to the suture 146 throughthe tool 100, a collapsible portion 150 of the collapsible tube engagesthe soft tissue 126. As seen in FIGS. 32-33B, once the collapsibleportion 150 of the collapsible tube is set, the tool 100 can be removedfrom the insertion guide 115. At this point, the end of the longitudinaltube can be removed, or can be tied to the suture 146.

FIGS. 34-36 represent an alternate method for coupling a sutureconstruction 104 to the fastener 102. Shown is a fastener 102 beingpassed through the loop of the suture. In this regard, the fastener 102is passed through the loop of the suture prior to insertion of thefastener 102 within the bore 136 in the bone. After removal of the tool100, tension is applied to the ends of the suture to constrict thecollapsible portion 150 of the collapsible tube. This tensioning pullsthe soft tissue 146 into a position with respect to the fastener 102.

As shown in FIGS. 37 and 38, the fastener 102 can have an associatedintegral loop 120. The integral loop 120 can be a suture or can be anintegral polymer construction. The compressible tube 122 can be threadedthrough the integral loop 120. Application of tension onto the suturecauses the collapsible portion 150 of the collapsible tube to bearagainst the integral loop 120 and the soft tissue. It is envisioned theintegral loop can be elastically deformable or can be fixed with respectto the fastener.

FIG. 39 represents a suture construction coupled to a two-piece fastener102. The suture construction 104 can be threaded through the apertureformed within the first or second portions of the fastener 102. Asshown, an integrally formed collapsible tube portion 148 can bedisclosed within the aperture of the fastener. Upon application oftension onto the suture, the tension will cause the collapse of thissecond collapsible tube portion 148, thus locking the suture to thefastener body 102.

FIGS. 40-44 represent an alternative system and method of coupling softtissue to bone. By way of non-limiting example, a fastener 102 can becoupled to the bone as described above and shown in FIGS. 23-30.Subsequent to this, the collapsible portion 150 of the tube 104 can bepassed through the soft tissue 126.

As best seen in FIGS. 40-42, a drive tool 160 is used to form a softtissue engagement site 162 in a bone structure. The tool 160 has a drive(not shown) which rotates a bone cutting bit 164. The bone cutting bit164 has a first portion 166 configured to drill a hole 167 throughcortical bone and a threaded second portion 168. The threaded secondportion 168 is configured to cut threads in the cortical 169 andcancellous bone 171 structures. This is accomplished by advancing thecutting bit 164 into the bone at a predetermined rate while rotating thebit at a predetermined speed. As shown in FIG. 41, after the secondportion 168 has entered the cancellous bone 171, the bit is rotatedwhile keeping the rotating tool 160 in a substantially stationaryposition. The thread cutting threads of the second portion 168 thendisplace cancellous bone 171, forming the cavity 162. The bit is removedby rotating the thread cutting threads through the threads formed in thecortical bone 169.

As shown in FIG. 43, the collapsible tube 104 of suture anchor is passedthrough passage 167 and into the cavity 162. In this regard, aninsertion tool 173 can be used to insert the collapsible tube 104 intothe cavity 162. As shown in FIG. 44, tension is applied to the end 172of the suture anchor, thus causing the collapsible portion 104 of theanchor.

The description of the invention is merely exemplary in nature and,thus, variations that do not depart from the gist of the invention areintended to be within the scope of the invention. For example, any ofthe above mentioned surgical procedures is applicable to repair of otherbody portions. For example, the procedures can be equally applied to therepair of wrists, elbows, ankles, and meniscal repair. The suture loopscan be passed through bores formed in soft or hard tissue. It is equallyenvisioned that the loops can be passed through or formed around anaperture or apertures formed in prosthetic devices e.g. humeral, femoralor tibial stems. Further, the suture material and collapsible tubes canbe formed of resorbable material. Such variations are not to be regardedas a departure from the spirit and scope of the invention.

What is claimed is:
 1. A method for coupling soft tissue to bonecomprising: forming a first bore in bone; forming a second bore in bone;positioning a first anchor in the first bore, the first anchor having afirst self-locking adjustable suture construct extending therefrom, thefirst construct including a first adjustable loop, a second adjustableloop, and a pair of first ends; positioning a second anchor in thesecond bore, the second anchor having a second self-locking adjustablesuture construct extending therefrom, the second construct including athird adjustable loop, and a second end; positioning the firstadjustable loop relative to the soft tissue; positioning the secondadjustable loop about the third adjustable loop; and tensioning the pairof first ends and the second end to pull the first adjustable loopagainst the soft tissue, couple the second adjustable loop to the thirdadjustable loop, pull the second adjustable loop against the softtissue, and pull the third adjustable loop against the soft tissue tothereby couple the soft tissue to the bone.
 2. The method of claim 1,wherein the first bore is formed spaced apart from the second bore. 3.The method of claim 1, further comprising coupling the first adjustableloop to the soft tissue by inserting a first coupling element throughthe soft tissue.
 4. The method of claim 1, further comprising couplingthe second adjustable loop to the third adjustable loop by inserting asecond coupling element through the soft tissue.
 5. The method of claim1, wherein positioning a first anchor in the first bore includespositioning a first rigid anchor in the first bore.
 6. The method ofclaim 5, wherein positioning a second anchor in the second bore includespositioning a second rigid anchor in the second bore.
 7. The method ofclaim 1, further comprising coupling the first adjustable loop to thesoft tissue with a first collapsible tube.
 8. The method of claim 1,further comprising coupling the second adjustable loop to the thirdadjustable loop with a second collapsible tube.
 9. The method of claim7, further comprising coupling the first collapsible tube to the firstadjustable loop with a first coupling loop.
 10. The method of claim 8,further comprising coupling the second adjustable loop to the thirdadjustable loop with a second coupling loop.
 11. The method of claim 1,wherein the first construct includes a passage portion defined by a bodyof a suture used to form the construct, the passage portion allowingportions of the first and the second adjustable loops to slide relativeto and through the passage portion to adjust a size of the first and thesecond adjustable loops, the soft tissue being coupled to an end of thefirst and the second adjustable loops opposite to the passage portion.12. The method of claim 11, further comprising attaching the firstconstruct to the first anchor by attaching the passage portion to thefirst anchor.
 13. A method for coupling soft tissue to bone comprising:inserting a first anchor in a first bone bore, the first anchor having afirst self-locking adjustable suture construct extending therefrom, thefirst construct including a first adjustable loop, a second adjustableloop, and a pair of first ends; inserting a second anchor in a secondbone bore, the second anchor having a second self-locking adjustablesuture construct extending therefrom, the second construct including athird adjustable loop, and a second end; positioning the firstadjustable loop relative to the soft tissue; compressing a firstcoupling element connected to the first adjustable loop against the softtissue by tensioning the pair of first ends; and connecting the secondadjustable loop to the third adjustable loop with a second couplingelement and compressing both the second adjustable loop and the firstadjustable loop against the soft tissue by tensioning the pair of firstends and the second end.
 14. The method of claim 13, wherein insertingthe first anchor in the first bore includes inserting a first rigidanchor in the first bore; and wherein inserting the second anchor in thesecond bore includes inserting a second rigid anchor in the second bore.15. The method of claim 13, further comprising inserting the firstcoupling element through the soft tissue and collapsing the firstcoupling element against the soft tissue by tensioning the pair of firstends; and collapsing the second coupling element against the secondadjustable loop by tensioning both the pair of first ends and the secondend.
 16. The method of claim 13, further comprising pulling the secondcoupling element through the tissue to the second anchor and thusconnecting the second adjustable loop to the third adjustable loopbetween the bone and the soft tissue.
 17. The method of claim 13,wherein the first construct is formed from a suture having a bodyforming a passage portion that defines an internal bore, wherein thepair of first ends of the suture pass through the internal bore andextend therefrom to form the first and the second adjustable loops, thefirst and the second adjustable loops having a first part at the passageportion and a second opposite part configured to receive the softtissue.
 18. The method of claim 17, further comprising attaching thefirst construct to the first anchor by attaching the passage portion tothe first anchor.
 19. A method for coupling soft tissue to bonecomprising: positioning a first anchor in a first bone bore, the firstanchor having a first self-locking adjustable suture construct extendingtherefrom, the first construct including a first adjustable loop, asecond adjustable loop, and a pair of first ends; positioning a secondanchor in a second bone bore, the second anchor having a secondself-locking adjustable suture construct extending therefrom, the secondconstruct including at least a third adjustable loop, and at least onesecond end; positioning the first adjustable loop relative to a firstportion of the soft tissue; collapsing a first coupling elementconnected to the first adjustable loop against the soft tissue bytensioning the pair of first ends; collapsing a second coupling elementconnected to the third adjustable loop against the second adjustableloop to couple the second adjustable loop to the third adjustable loopby tensioning the second end; and compressing the second adjustable loopand the third adjustable loop against the soft tissue by tensioning boththe pair of first ends and the second end.
 20. The method of claim 19,wherein positioning the first anchor in the first bone bore includespositioning a first rigid anchor in the first bone bore; and whereinpositioning the second anchor in the second bone bore includespositioning a second rigid anchor in the second bone bore.
 21. Themethod of claim 19, further comprising coupling the second adjustableloop to the third adjustable loop between the second anchor and the softtissue.
 22. The method of claim 19, further comprising closing the firstadjustable loop against the soft tissue by tensioning the pair of firstends.
 23. The method of claim 22, further comprising closing the thirdadjustable loop against the soft tissue and closing the secondadjustable loop against the third adjustable loop by tensioning both thepair of first ends and the pair of second ends.